Healthcare Provider Details

I. General information

NPI: 1740701093
Provider Name (Legal Business Name): KHALID B MOHAMMED DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13127 VAIL RIDGE DR
RIVERVIEW FL
33579-7196
US

IV. Provider business mailing address

13127 VAIL RIDGE DR
RIVERVIEW FL
33579-7196
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-6199
  • Fax:
Mailing address:
  • Phone: 813-661-6199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number5101023548
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberOS20816
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberOS20816
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101023548
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: